Should we Abandon the Cuff Leak Test to Predict Post-Extubation Stridor?

Abstract

Post-extubation stridor (PES) is an iatrogenic complication of intubation and is secondary to acute upper airway obstruction that develops after extubation. PES severity widely varies from a patient to another, but may lead in some cases to reintubation in technically difficult conditions. PES represents one of the primary causes of respiratory distress developing after extubation. For obvious reasons, the presence of the tracheal tube renders difficult the prediction of PES before extubation. The cuff leak test has been developed to overcome this difficulty and represents to date the gold standard for PES diagnosis. However, given its low positive predictive value, a positive test must be seen as indicator of an increased risk for PES rather than reason to postpone extubation. The elevated negative predictive value of cuff leak test more reflects the low incidence of PES than the intrinsic characteristics of the test. Thus, systematic cuff leak test before extubation of unselected critically ill patients should be abandoned since it may expose an excessive number of patients to the risk of unjustified prolonged mechanical ventilation. In selected high-risk patients, the value of cuff leak test deserves further evaluation.